I understand that if I do not pay as services are rendered, a service charge may be added each month, if there is an outstanding balance. Should this account become delinquent, I understand that I am responsible for any and all legal fees, court costs, and collection fees involved as a result of any collection activity.
I hereby authorize Pediatrics After Hours and MEK Pediatrics, PLLC to treat and furnish information to insurance carriers concerning the diagnosis and treatment of the patient listed above. I understand that I am responsible for all charges, regardlessof insurance coverage. I also understand that payment (co-pays, deductibles, etc.) is due at time of service.